QUESTION

When I went to the pharmacy to get my birth control, I had a co-pay. I thought all contraceptive coverage had to be free?

Post enrollment issues | Employer-Sponsored Coverage
ANSWER

In general, health plans must cover all 18 methods of contraceptive coverage that the FDA has currently approved for women with reproductive capacity unless the health plan is grandfathered. The list of approved contraceptive methods is available here. While health plans must cover all methods approved for women, they are not obligated to cover each form of contraception under each method. For example, if a health plan covers both a generic and brand name birth control pill, it can impose cost-sharing on the brand name over the generic as part of its medical management. However, if your doctor determines you should take the name brand birth control because it’s medically appropriate, the health plan must cover the brand name birth control without cost sharing.

Note that federal rules allow eligible organizations including employers and insurers that have an objection based on “sincerely held religious beliefs or moral convictions” to exclude some or all contraceptives from a health plan, and a previous process in place to ensure enrollees still had access to contraceptive coverage is no longer required. The U.S. Supreme Court recently allowed these rules to go into effect, but they are subject to further legal proceedings. And, some fully insured employer coverage is also subject to state laws that require contraceptive coverage. To determine if your current policy covers contraceptives, and what methods are covered, check with your plan administrator. You should be able to request plan materials that list covered and excluded services, including contraceptives.

This is an area that is constantly evolving. If you have a question, you should ask your employer or insurer what is covered or contact the National Women’s Law Center via information here if your employer or insurer says contraception is not covered or you experience cost-sharing that is not allowed under the law. Also, check with your state insurance department to see if there are other ways to access free or low-cost contraception if your employer plan does not provide coverage. (CMS, ACA Implementation FAQs-Set 26, May 11, 2015; 29 CFR § 2520.104b-2; 45 CFR. §§ 147.131 – 147.133).

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